Review of Abortion Pills Go Global: Reproductive Freedom Across Borders By Sydney Calkin, Oakland, CA: University of California Press. 2023. 278 pp.

Reviewed Book

Abortion Pills Go Global: Reproductive Freedom Across Borders By Sydney Calkin, Oakland, CA: University of California Press. 2023. 278 pp.

Cover of Abortion Pills Go Global (2023)

Elise Andaya

University at Albany

In this carefully researched and timely study, feminist geographer Sydney Calkin follows medication abortion (MA; also known as abortion pills) as it traverses physical and metaphorical borders, transforming the landscape of abortion rights and access as it does so. Drawing on interviews with activists, abortion providers, lawyers, and politicians, as well as written sources from court documents to social media, Calkin makes a compelling case for attending to what she calls the “geography of abortion”—the spatial arrangement of rights and access—as well as “regulatory geography” (the laws governing abortion in specific states and countries) in analyses of abortion politics.

While there is a long history of pregnant people crossing county and national borders for abortion care, in the case of MA, it is the technology that travels. Small, mass-produced, relatively cheap, and hard to detect and intercept, it offers pregnant people the option of safely ending pregnancies in their own homes. Following MA and its effects, Calkin traces the formal and informal networks through which MA circulates in the United States, Poland, Ireland, and Northern Ireland, becoming variously licit and illicit as it passes through different legal and geographic territories.

For Calkin, much of MA’s transformative potential lies in its ambiguity and the fact that existing anti-abortion laws often fit poorly with these new forms of abortion access (which is why MA has become a particular target for anti-abortion activism in the US post-Dobbs era). She writes, “abortion pills can slip—metaphorically—between legal categories to scramble ideas about what abortion is and who does it, while they can also slip—physically—across territorial boundaries in quantities large enough to supply a mass movement” (126). Ideally, MA involves mifepristone, which blocks the hormones that sustain pregnancy, followed 24 to 48 hours later with misoprostol, which produces uterine contractions. While mifepristone is used only to interrupt a pregnancy, misoprostol can be used to treat stomach ulcers, manage incomplete miscarriages, and control postpartum hemorrhage. Misoprostol’s ambiguity is thus useful in contexts where abortion is criminalized; while self-managed abortions with misoprostol alone are less effective than the combined regimen (87% vs. 95%), Calkin notes that elderly people might be sent to obtain misoprostol at a local pharmacy without fear of suspicion. Compounding this metaphorical slippage is the fact that MA is virtually undetectable in the body; a self-managed abortion might also be identified as a miscarriage or heavy menstrual period. For those living in geographic zones with total or near-total abortion bans, cross-border access to medication abortion—whether through online mail order from companies in India, from international organizations like Women on Waves, or hand-delivered by border-crossing activists—may be their only hope for ending a pregnancy.

Chapter 1 sets the stage for the book, following abortion pills from India, where most are manufactured, as they flow into international distribution. Chapters 2 and 3 then take up the circulation of medication abortion in the post-Dobbs US; Chapter 2 examines MA’s “official life” and the legal strategies that pro- and anti-abortion rights activists have used to integrate or block its use in clinical practice while Chapter 3 considers the “unofficial” flow of MA outside formal healthcare space.

Moving to Poland, Chapter 4 describes the country’s abortion landscape as the liberal abortion access of the Soviet era has been dismantled by a coalition of conservative legislators, civil groups, and the Catholic Church. As Calkin points out, Poland’s abortion ban exists alongside a “strategic ignorance” of the extent of self-managed abortions, allowing anti-abortion legislators and supporters to claim that abortion bans succeed as policy. Chapter 5 builds upon this argument by discussing the pathways through which pregnant people in Poland obtain and use MA—primarily doctors, transnational activists, and online pill vendors—showing the different levels of support, education, reliability, and risk that comes with each pathway.

Chapters 6 through 8 examine the impact of MA on abortion access and broader reproductive politics in Ireland and Northern Ireland. In Ireland, abortion was decriminalized in 2018, driven by the (inter)national public outcry over the death of Savita Halappanavar, who died of sepsis after she was refused life-saving abortion care for an incomplete second trimester miscarriage. Using Ireland as a case study for the role of MA in reshaping reproductive politics, Calkin argues that the availability and widespread usage of MA was central to political reform as politicians recognized the prevalence of abortion despite the constitutional ban. By contrast, across the border in Northern Ireland, a source of much pill traffic to Ireland, the state attempted to criminalize not only pill distributors but pill users. Even after decriminalization in 2019, abortion access is still limited (up to 12 weeks) and access is extremely uneven, highlighting the key point that “removing laws that criminalize abortion is not the same as creating services that give people local and affordable access” (189).

Throughout, Calkin shows how MA’s capacity to slip between metaphorical and physical boundaries has transformed the landscape of abortion, allowing pregnant people to obtain safe and effective abortions even in places where it is criminalized. In Ireland, MA’s widespread availability supported abortion’s social decriminalization—its perception by the public—that in turn spurred movements towards legal decriminalization. Yet MA alone is not sufficient to achieve progressive abortion reform; as feminists have long reminded us, reproductive freedom is fundamentally social and political endeavor rather than a technological one. MA’s transformative power is constrained when people lack information about how to properly and safely self-manage abortions, cannot afford or do not know where to obtain pills, or face criminal charges for self-managing an abortion.

Title notwithstanding, this book is not global in scope. Rather, it is a compelling analysis of MA and its role in the politics of reproductive rights and access in four majority-white countries in the Global North. Calkin recognizes this bias and addresses her reasons for focusing on these countries in the Introduction. Still, given its comparative framework, it would have been useful to learn more about how MA has shaped reproductive politics in countries of the Global South and its relationship to reproductive justice efforts there. That caveat aside, this is timely and important reading for anyone interested in abortion politics, pharmaceutical circulation, and comparative policy, and would be of interest to upper-level undergraduate or graduate students in gender studies, law and policy, and human geography, as well as in anthropology.